Metacognitions, anxiety, and distress related to motor fluctuations in Parkinson's disease Richard G. Brown a , Bruce A. Fernie a,b, ⁎ a King's College London, Institute of Psychiatry, Department of Psychology, London, UK b CASCAID, South London & Maudsley NHS Foundation Trust, London, UK abstract article info Article history: Received 13 August 2014 Received in revised form 22 September 2014 Accepted 23 September 2014 Available online xxxx Keywords: Parkinson's disease Motor-fluctuations Distress Metacognition Off-periods Objective: This study tested the relationship between metacognitive factors, intolerance of uncertainty, anxiety, and the predictability of, and distress associated with, acute fluctuations in symptoms in idiopathic Parkinson's disease (PD), when controlling for disease parameters. Method: 106 adults with idiopathic PD (30 females; M age = 65.3; 90% white) participated in this study, with 93 of them reported experiencing off-periods. A cross-sectional design was employed that utilised: the Hospital De- pression and Anxiety Scale, Movement Disorder Society revision of the Unified Parkinson's Disease Rating Scale, the Addenbrooke's Cognitive Examination — Revised, the Intolerance of Uncertainty Scale, and the Metacognitions Questionnaire 30. Correlation analyses, hierarchical regression analysis, and ordinal regression analysis were used to test the experimental hypotheses. Results: Anxiety was not significantly associated with motor symptom severity or cognitive functioning, while metacognitive factors were significantly related to anxiety when controlling for motor experiences of daily living and intolerance of uncertainty, R 2 = 0.56, F(1,82) = 15.04, p b 0.001 (adjusted R 2 = 0.53). For participants with motor fluctuations, no association was found between predictability of, and distress associated with, off-periods. Metacognitions concerning uncontrollability and danger were significantly related to off-period distress when controlling for motor experiences of daily living, intolerance of uncertainty, and other metacognitive factors, χ 2 (1) = 20.52, p = 0.001. Conclusion: Metacognitive factors play a role in anxiety and off-period distress in PD and this is discussed in terms of the Self-Regulatory Executive Function model. Interventions from metacognitive therapy are potential means to ameliorate off-period distress and anxiety in PD. © 2014 Elsevier Inc. All rights reserved. Introduction Parkinson's disease (PD) is a progressive neurological disorder with an estimated population prevalence of approximately 300 per 100,000, increasing to 1%, over the age of 60 years and up to 4% in the oldest age groups [1]. PD is typically considered a disorder of movement with symptoms of slowed and reduced amplitude voluntary action, tremor, and rigidity affecting limb and eye movement, in addition im- paired control of balance, swallowing, and speech. A range of disabling non-motor symptoms are also commonly experienced including de- pression, anxiety, psychosis, cognitive impairment, autonomic dysfunc- tion, fatigue, and pain. Motor and non-motor disability increase with disease progression despite symptomatic treatment using levodopa, do- pamine agonists, or other drugs that modify brain dopamine levels. With disease progression and increasing duration of treatment, effectiveness gradually declines. In those treated with levodopa, fluctu- ations in symptom severity over the course of the day commonly devel- op. These include ‘wearing off’ (a relatively predictable re-emergence of symptoms towards the end of a medication dose); ‘on/off fluctuations’ (unpredictable and sudden recurrence of Parkinsonian symptoms); ‘delayed on’ (unpredictably increased time between ingestion of a dose and motor benefit), and ‘dose failure’ (unpredictable failure of a dose to provide usual benefit) [2]. In addition to worsening of motor symptoms during ‘off-periods’, the emergence or exacerbation of distressing non-motor symptoms is also reported by many individuals including pain, fatigue, drenching sweats, depression, and anxiety. Currently, fluctuations and associated symptoms are managed by al- terations in drug regimen but this becomes increasingly difficult with disease progression. This offers potential to develop adjunctive psycho- logical approaches to manage individual symptoms (e.g. depressed mood, pain, or fatigue) or reduce the level of associated subjective dis- tress. There is evidence that traditional CBT treatment approaches can be helpful in reducing depressive and anxiety symptoms in PD [3,4] al- though not specifically in the context of motor fluctuations. One challenge of CBT is the limits on reality-testing of thoughts and beliefs about PD (e.g. Journal of Psychosomatic Research xxx (2014) xxx–xxx ⁎ Corresponding author at: Department of Psychology, Institute of Psychiatry, King's College London, Henry Wellcome Building, De Crespigny Park, London SE5 8AF, UK. Tel.: +44 7779 300 427; fax: +44 20 7848 5310. E-mail address: bruce.fernie@kcl.ac.uk (B.A. Fernie). PSR-08900; No of Pages 6 http://dx.doi.org/10.1016/j.jpsychores.2014.09.021 0022-3999/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Psychosomatic Research Please cite this article as: Brown RG, Fernie BA, Metacognitions, anxiety, and distress related to motor fluctuations in Parkinson's disease, J Psychosom Res (2014), http://dx.doi.org/10.1016/j.jpsychores.2014.09.021